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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sioov grofehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be 29rrected within Qays of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (END)address <br /> at the top of this form within 30 days of receipt of the Inspection Report. NSC 254o4.1.2(c)(1) <br /> All cgrrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 day unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: Ail EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, andlor photos verifying <br /> corrections <br /> Inspection Date: December 22, 2014 Inspected By: JAMIE DE LA ROSA <br /> Facility Address: 14971 N HWY 88 , LODI EPA ID:_ 4 1 00 0 31 '{9 <br /> 1 certify under penalty of law that: <br /> 1 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2 1 have personally examined the following documentation submittedas pr of compliance FOR EACH VIOLATION <br /> c <br /> and I believe the informabon to be true, accurate, and omplete: <br /> Photos Paperwork_ Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br /> and/or im nment for known vviolatio s. (HSC 5191) <br /> Name:.— -- <br /> Signature: Date: <br />